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Brookview Healthcare Center

214 Harding Street, Defiance, OH 43512 · For profit - Limited Liability company · 89 certified beds · (419) 784-1014 Medicare & Medicaid certified

Call the home — (419) 784-1014 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1018 Ralston Ave · (419) 843-7780 · Call to confirm hours
Pharmacy
1804 N Clinton St · (419) 784-2404 · Call to confirm hours
Grocery
1340 W High St · (419) 782-0950 · Call to confirm hours
Park
829 OH-424 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.6%5.3%15.4%better than state — see note marked double-dagger below the table
Long-stay residents who lose too much weight7.7%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.2%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.4%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms69.3%30.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened6.7%6.1%16.1%typical for the state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication37.7%25.5%18.9%worse
Long-stay residents given the seasonal flu vaccine85.1%94.5%95.3%worse
Long-stay residents with pressure ulcers2.5%3.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.3%21.4%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.8%8.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine41.7%75.6%79.4%worse
Short-stay residents rehospitalized after admission19.9%24.9%22.6%better
Short-stay residents with an outpatient ER visit18.5%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.871.731.67worse
Long-stay outpatient ER visits per 1,000 resident days4.241.801.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.0%U.S. median 51.5%
Got home and stayed home
13.1%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.0%CMS range 42.8–64.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.1%CMS range 8.8–19.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge46.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.5–14.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.33
RN hours/ resident / day
1.09
LPN hours/ resident / day
1.65
Aide hours/ resident / day
3.06
Total nurse hours/ resident / day
0.26
RN hoursweekends
53.2%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 89 beds and averages 73.6 residents a day — about 83% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.65 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.77 hrs/resident/day on weekends vs 3.18 on weekdays — 13% thinner on weekends. RN hours go from 0.36 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-03-27)
11
at the previous standard inspection (2022-08-01)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, medical record review, hospital record review, staff interview, and policy review, the facility failed to ensure residents received timely treatment for constipation. This resulted in actual harm after Resident #14 had no bowel movement (BM) for seven days in the facility and was admitted to the hospital the following day with abdominal pain and was found to be impacted with stool. This affected one (#14) resident reviewed for bowel movements. The facility census was 72. Findings include: Review of the medical record for Resident #14 revealed an admission date of 12/08/24 with diagnoses of constipation, anxiety, and generalized abdominal pain. Review of the comprehensive admission assessment completed 12/14/24 revealed Resident #14 had intact cognition and was occasionally incontinent of bowel. Constipation was not present at the time of the assessment. Resident #14's care plan, reviewed on 03/26/25, revealed a care area initiated 01/17/25 indicating Resident #14 was at risk for alteration in elimination constipation. The goal was for Resident #14 to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-07-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policies, the facility failed to ensure infection control measures were properly utilized during wound care. This affected one (#61) of one residents reviewed for wound care. The facility census was 69.Findings include:Review of the medical record for Resident #61 revealed she was admitted on [DATE] with diagnoses including unspecified open wound to the right ankle, muscle weakness, difficulty walking, malnutrition, psychoactive substance abuse, Charcot's joint of the right ankle, and osteomyelitis.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and did not display any behaviors at the time of the assessment. She required supervision to partial assistance with activities of daily living. She required surgical wound care with dressings to her foot.Review of physician orders for Resident #61 revealed an order dated 05/16/26 for enhanced barrier precautions to be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility investigation information, staff interview and review of facility policy, the facility failed to ensure timely medical follow up for residents following a fall with injury. This affected one Resident (#10) of three residents reviewed for falls. The facility also failed to complete a wound dressing change per the physician's orders. This affected one (#79) of five residents reviewed for wound dressing changes. The facility census was 74. Findings include:1. Review of Resident #10's medical record revealed an admission date of 12/09/25. Diagnoses included ovarian cancer, abdominal lining cancer, general anxiety disorder, type II diabetes, major depressive disorder, adult failure to thrive, dementia, difficulty walking, unsteady on her feet, dysphagia, disorientation, and osteoarthritis.Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #10 was cognitively intact. Resident #10…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure all medications ordered by the physician were administered to a resident. This affected one (#70) of eight residents review for medication administration. The facility census was 74.Findings include:Review of Resident #70's medical record revealed an admission date of 04/08/16. Diagnoses included Alzheimer's disease, diabetes mellitus due to underlying condition with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness.Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 03.Review of Resident #70's care plan dated 02/17/26 revealed Resident #70 was at risk for alteration in mood related to her diagnoses of anxiety, dementia, and depression with interventions that included to administer medications…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure resident were not administered medications they were identified as having allergies to. This affected one (#10) of three residents reviewed for medication allergies. Additionally, the facility failed to remove medication patches prior to administering/applying another medication patch. This affected one (#78) of eight residents observed for medication administration. The facility census was 74. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 12/09/25. Diagnoses included ovarian cancer, abdominal lining cancer, general anxiety disorder, type II diabetes, major depressive disorder, adult failure to thrive, dementia, difficulty walking, unsteady on her feet, dysphagia, disorientation, and osteoarthritis. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and policy review, the facility failed to ensure residents received interventions to offset significant weight loss. This affected two (#31 and #60) of three residents reviewed for significant weight loss. The facility census was 72. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 02/24/25 with diagnoses of dehydration and moderate protein-calorie malnutrition. Review of the initial comprehensive Minimum Data Set (MDS) assessment, dated 03/03/25, revealed Resident #31 had intact cognition and required set-up or clean-up assistance for eating. Further review of the medical record revealed Resident #31 was hospitalized overnight for altered mental status from 03/10/25 through 03/11/25. Review of the weight history for Resident #31 revealed he weighed 157.7 pounds on 03/10/25, and weighed 138.2 pounds on 03/11/25, upon return from the hospital. Review of the hospital discharge records, dated 03/11/25,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure resident's dialysis access sites were monitored by the facility. Additionally, the facility failed to ensure pre and post dialysis evaluations were completed. This affected two residents (#21 and #24) of two reviewed for dialysis. This facility census was 72. Findings include: 1. Review of the medical record of Resident #21 revealed an admission date of 02/21/25. Diagnoses included end stage renal disease and dependence on renal dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact, and diagnoses were listed. The assessment further indicated Resident #21 was on hemodialysis while a resident. Review of the physician orders revealed an order dated 02/24/25 to monitor the AV fistula for bruit and thrill every shift. A second order was placed on 03/25/25, after surveyor inquired, to monitor the left arm for bruit/thrill…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, medical record review, and staff interview, the facility failed to ensure residents received medications as ordered. This affected two (#21 and #123) of eight residents reviewed for medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #123 revealed an admission date of 03/11/25 with diagnoses of metabolic encephalopathy, and type 2 diabetes mellitus. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 03/17/25, revealed Resident #123 had intact cognition. Review of a discontinued physician order, active 03/11/25 through 03/19/25, revealed Resident #123 received Lactulose Oral Solution 10 grams (gm) per 15 milliliters (ml). Give 60 ml by mouth three times daily for hyperammonemia (elevated ammonia in the blood). Review of a discontinued physician order, active 03/19/25 through 03/26/25, revealed Resident #123's Lactulose Oral Solution dose increased to 75 ml three times daily. Review of the current physician…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of pharmacy recommendations, record review, and staff interview, the facility failed to ensure timely response to pharmacy recommendations for residents on psychotropic medications. This affected three (#11, #60, and #62) of five residents reviewed for pharmacy recommendations. The facility census was 72. Findings include: 1. Review of the medical record of Resident #11 revealed an admission date of 06/14/11. Diagnoses included anxiety disorder, schizoaffective disorder, major depressive disorder, paranoid schizophrenia, long-term use of opiate analgesic, and chronic pain syndrome. Review of the, Physician Recommendation Forms, the facility failed to ensure a physician addressed the recommendations of the pharmacist. On 03/09/24 the pharmacist indicated hydroxyzine 25 milligrams (mg) was ordered twice daily and was due for an evaluation for continued use. On 04/10/24 the pharmacist indicated a quarterly review was due for further use of Trazadone 150 mg at bedtime, per State and Federal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, record review, staff interview, and policy review, the facility failed to ensure residents received insulin as ordered by the physician. This affected one (#123) of eight residents reviewed for medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #123 revealed an admission date of 03/11/25 with diagnoses of metabolic encephalopathy and type 2 diabetes mellitus. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 03/17/25, revealed Resident #123 had intact cognition. Review of the baseline care plan dated 03/13/25 revealed Resident #123 had diabetes. Review of the current physician order dated 03/11/25 revealed Resident #123 received Humalog KwikPen Subcutaneous Solution Pen-Injector 100 units per milliliter (ml) (Insulin Lispro), inject 8 units subcutaneously (SQ) three times a day for diabetes mellitus (DM). The scheduled dosing times were 8:00 A.M., 11:00 A.M. and 5:00 P.M. Review of the current physician order dated 03/13/25 revealed Resident #123 received Humalog Injection…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure staff wore gloves when administering injections. This affected three residents (#21, #122, and #123) observed for insulin injections. Additionally, the facility staff did not disinfect a glucometer between resident use. This affected two residents (#21 and #122). Further, the facility failed to ensure staff wore proper personal protective equipment and practiced appropriate hand hygiene. This affected two residents (#122 and #123). The facility census was 72. Findings include: 1. Review of the medical record of Resident #21 revealed an admission date of 02/21/25. Diagnoses included type II diabetes mellitus. Review of the medical record of Resident #122 revealed an admission date of 03/19/25. Diagnoses included type II diabetes mellitus. Review of the medical record of Resident #123 revealed an admission date of 03/11/25 Diagnoses included type II diabetes mellitus. Observation on 03/26/25 at 8:05 A.M. revealed Licensed Practical Nurse (LPN) #400 administered seven units of Humalog insulin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-01-11 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to follow their policy titled Weight Management Program and Weight Loss by ensuring the physician was notified of significant weight loss. This affected three (#10, #56 and #78) out of three residents reviewed for weight loss. The facility census was 79. Findings Include: 1. Review of the medical record for Resident #56 revealed an admission date of 07/08/23 with a diagnosis of multi-system degeneration of autonomic nervous system. Review of the physician orders for 01/23 revealed a diet order of regular mechanical soft, chopped meat diet with thin liquids and house supplement two times per day. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #56 required set-up for meals and was identified for weight loss and required a mechanically altered diet. Review of the care plan revised 10/23 for Resident #56 revealed she was care planned for nutritional problems. Review of the dietician note…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and policy review, the facility failed to ensure appropriate sanitation when serving meals and failed to keep pureed meat at a safe holding temperature to potentially prevent foodborne illness. This had the potential to affect 62 of 62 residents. The facility census was 62. Findings include: 1. Observation on 07/25/22 at 11:12 A.M., of Assistant Dietary Supervisor (ADS) #467 checking the holding temperature of pureed fish revealed the temperature of the fish on the holding steam table was 120 degrees Fahrenheit. Interview of ADS #467, at the time of the observation, verified the pureed fish was 120 degrees. ADS #467 stated she set the temperature on the holding table at 175 degrees Fahrenheit but she was unsure of what the hot food holding temperature should be to prevent foodborne illness. ADS #467 stated the pureed fish had set outside of the steam table a little longer while she was getting other food ready. ADS #467 was unsure how long the pureed fish had been left sitting before placing on the holding table. 2. Observation on 07/25/22 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-08-01 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, infection control log review, tuberculosis risk assessment review, review of personnel files, and review of a facility policies, the facility failed to monitor for trends and patterns of infections in the facility based on facility policy, failed to sanitize hands and wear appropriate personal protective equipment (PPE) during resident care interactions, and failed to ensure the facility followed their tuberculosis risk assessment in monitoring staff for potential tuberculosis infections. This deficiency had potential to affect 62 of 62 residents residing in the facility. The census was 62. Findings include: 1. Review of infection control logs from May, June, and July 2022 revealed each resident with an infection was placed on a spreadsheet and the following information documented: the unit the resident resided on the date of the infection, the resident's name, room number, signs and symptoms including the date, the site of the infection, if the infection was a urinary tract infection did the resident have a urinary catheter, culture or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-01 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. A total of 15 medications errors were observed out of 28 medications administered which resulted in a medication error rate of 53.57 percent (%). The census was 62. Findings include: 1. Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, chronic obstructive pulmonary disease, diabetes mellitus type II, aphasia, and essential hypertension. Review of physician orders dated 06/21/21 revealed Resident #56 was ordered the nerve pain medication Gabapentin 100 milligrams (mg) by mouth three times daily, the acid reducer famotidine 20 mg by mouth twice daily, and the supplement ferrous sulfate 325 mg by mouth three times daily. Review of a physician order dated 11/03/21 revealed Resident #56 was ordered the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-08-01 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medication administration was completed without significant medication errors. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. The census was 62. Findings include: 1. Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, chronic obstructive pulmonary disease, diabetes mellitus type II, aphasia, and essential hypertension. Review of physician orders dated 06/21/21 revealed Resident #56 was ordered the nerve pain medication Gabapentin 100 milligrams (mg) by mouth three times daily. Review of a physician order dated 07/18/22 revealed Resident #56 was ordered the antipsychotic medication Seroquel 25 mg by mouth twice daily. Review of the July 2022 medication administration record (MAR) revealed Resident #56's Seroquel was scheduled to be administered between 7:00 A.M. and 11:00 A.M. and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of policy, the facility failed to ensure a residents code status was identified in the medical record. This affected one (#47) of three residents reviewed for advanced directives. The facility census was 62. Findings include: Review of the medical record for Resident #47 revealed an admission date of 06/12/22. Diagnoses included Alzheimer's disease, hypertension, atrial fibrillation, cerebral infarction, and type II diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Additional review of Resident #47's electronic medical record (EMR) and paper chart revealed no information related to the Resident's code status. Interview on 07/26/22 at 2:41 P.M., with Licensed Practical Nurse (LPN) #438 and Registered Nurse (RN) #457 verified Resident #47's code status was not identified in the EMR or paper chart. LPN #438 stated since there was no code status identified, Resident #47 would be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of policy, the facility failed to ensure fingernails were trimmed and maintained in a sanitary manner. This affected one (#13) of three reviewed for activities of daily living. The census was 62. Findings include: Review of Resident #13's medical record revealed an admission date of 10/05/18. Diagnoses included chronic obstructive pulmonary disease, obsessive-compulsive disorder, need for assistance with personal care, hyperlipidemia, adult failure to thrive, dementia with behavioral disturbance, and diabetes mellitus type II. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, was assessed to require extensive one person physical assistance with personal hygiene, and assessed with no rejection of care during the assessment time period. Observation on 07/25/22 at 3:50 P.M., revealed Resident #13 sitting in the reclining chair in his…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation, staff interview, and policy review, the facility failed to implement pressure relief interventions to prevent the development of pressure ulcers. This affected one (#20) of two residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers acquired in the facility in a census of 62. Findings include: Review of Resident #20's medical record revealed an admission date of 05/31/21, with diagnoses including hypertensive heart disease with failure, dementia with behavioral disturbances, congestive heart failure , Type II diabetes, anxiety disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/29/22 revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS) indicating the resident has severe cognitive deficits. She displayed verbal and physical behaviors toward others on 1- 3 days of the assessment period. She requires extensive assistance of two staff members for bed mobility and transfers. She is not ambulatory. She is frequently incontinent of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, and policy review, the facility failed to implement fall prevention interventions for two residents (#47 and #48) of three residents reviewed for falls. The facility census was 62. Findings include: 1. Review of Resident #48's medical record revealed an admission date of 09/27/21, with diagnoses including Parkinson's Disease, dementia with behaviors, muscle wasting and aphasia. Review of significant change in status Minimum Data Set (MDS) assessment, dated 07/07/22, revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive deficits. He did not exhibit any behaviors and had no falls since the last assessment. Review of the plan of care updated 07/07/22 stated Resident #48 is at risk falls and fall related injuries. He has a history of having recurrent falls, but has not had any serious injury caused by these; has an unsteady gait; has standing balance impairments due to Parkinson's, tremors,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, the facility failed establish the medical necessity for the continued use of an indwelling catheter, maintain the catheter for privacy and to prevent potential infections. This affected one (#44) of one resident reviewed for the extended use of a indwelling catheter. The census was 62. Findings include: Review of Resident #44's medical record revealed an admission date of 06/08/, with diagnoses including: morbid obesity, chronic obstructive pulmonary disease, hypertension, sleep apnea, depression, and gout. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive deficits. He had no behaviors. The resident has a indwelling catheter in place and is frequently incontinent of bowel. Review of the MDS Care Area Assessment (CAA) dated 06/15/22 stated the urinary incontinence CAA was triggered secondary to use of an indwelling catheter. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-01 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to ensure blood glucose monitoring was completed as ordered. This affected one (#56) of five residents observed during medication administration. The facility identified 16 residents with physician orders for blood glucose monitoring. The census was 62. Findings include: Review of Resident #56's medical record revealed an admission date of 03/11/20. Diagnoses included unspecified dementia with behavioral disturbances, diabetes mellitus type II, muscle weakness, chronic obstructive pulmonary disease, aphasia, and essential hypertension. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was assessed with moderately impaired cognitive skills for daily decision making. Review of a physician order dated 06/21/21 revealed Resident #56 was ordered Humalog insulin injected subcutaneously and to be administered via a sliding scale. The ordered sliding scale was as follows: for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-01 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's Care Planning Policy, the facility failed to provide one of 36 sampled residents, (Resident (R) 564), and their representative with a baseline care plan, or a written baseline care plan summary. The facility also failed to ensure R564's baseline care plan included a pertinent medical condition, and that it addressed the resident's overall goal and expectation to return to community living. Findings include: Review of R564's electronic and paper medical records documented the facility admitted the resident on 11/23/18 and re-admitted her on 06/27/19 and 07/24/19 with diagnoses that included type II diabetes. Review of the resident's dually-coded 5-day/admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/19, revealed R564 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated her cognitive skills were intact, and that her active diagnoses included diabetes. The Assessment and Goal Setting section of the MDS indicated the resident participated in the assessment;…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-08-01 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide resident-centered activities for one of 36 sampled residents, (Resident (R) 25). Findings include: Review of the hard copy medical record admission Record (resident's demographic information) revealed the facility admitted R25 on 07/17/18 and re-admitted the resident on 05/15/19 with diagnoses that included dementia and legal blindness. Review of R25's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/19 revealed the resident had severe cognitive impairment, rarely understood others, and could sometimes be understood by others. Further review of the MDS revealed a required section of the assessment titled, Section F: Preferences for Customary Routine and Activities, which documents the resident's daily preferences and activity preferences, had not been completed by the staff. Review of an activity assessment, dated 07/24/18, indicated R25 enjoyed arts and crafts, music, religious activities, and exercise. Further review of R25's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-08-01 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on infection control log review, staff interview, and review of a facility policy, the facility failed to thoroughly review antibiotic usage prescribed by the physician and monitor for outcomes of antibiotic usage. This had potential to affect 62 of 62 residents residing in the facility. The census was 62. Findings include: Review of infection control logs June and July 2022 revealed each resident with an infection was placed on a spreadsheet and the following information documented: the unit the resident resided on the date of the infection, the resident's name, room number, signs and symptoms including the date, the site of the infection, if the infection was a urinary tract infection did the resident have a urinary catheter, culture or organism if applicable, antibiotic use with stop and start date, if placed on isolation, if symptoms were present on admission, if the infection was acquired in the facility, and if the antibiotic usage met McGeer criteria (nationally-recognized infection surveillance criteria). Further review of the June and July 2022 infection control log…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIONSTONE CARE — 24 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 1 of 51.7-0.7 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 23 homes this chain runs (chain average 2.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LIONSTONE HZ OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2023
KAZARNOVSKY, SOLOMONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 01/01/2023
STEIN, ABBAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 01/01/2023
CUSNER, ADAMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/27/2025
DEGYANSKY, JEFFREYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
GOLDISH, ELIEZERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2023

CMS files one row per role, so the 18 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.0M
Net patient revenuemost recent cost report
-8.3%
Operating marginrevenue minus expenses
$352K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 9%Other / private 35%

This home reported $352K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$296per resident / day
operating cost
$9,010per month
≈ monthly operating cost
$274per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OH

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Ohio Medicaid page.

Typical monthly cost in Ohio
$9,186/mo
Nursing home (semi-private)
$10,389/mo
Nursing home (private)
$6,103/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 365447. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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